Should I have watched the pt die?

[doraku]

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I am currently in the MICU and have been carrying a patient who is literally on her deathbed. Today her K+ was well above 8.0 and her EKG started going through the expected changes at about 2pm. At that point, I had finished my work but wanted to stick around to see what would happen. By 4pm, I noticed I was meticulously calibrating her EKG and watching it slowly turn into a sine wave (but not quite). I don't know if it was the sadness of literally watching someone die or the fact that I had seen a patient die in front of me but I did not want to stay. I mentioned to the resident that I had finished all my notes, offered to help him with his work (he declined), and then suggested that I leave because I was getting upset. He looked at me with surprise and said "it shouldn't be too much longer," implying I should stay and was teased by the other residents for wanting to see her EKG convert to sine then asystole (which he admitted to). So I stayed for another half hour but I couldn't stand to watch that stupid EKG as the nurse got the atropine ready and we paged through ACLS protocol. Not to mention the fact that everyone was wrapped up in their work and I was left with this half dead women to watch her demise. I finally left and got a surprised reaction from the resident along with a dismissive "okayyy". Was that bad? Should I have stayed until she coded? I feel so horrible but on the other hand I also know that I will be in that situation more times than I can count and its not pleasant. I didn't want to see everyone rush in for the code or the family start screaming in despair when they find out their loved one passed. Although I realize I should not avoid that situation, I don't understand why I should subject myself to it unnecessarily. I was carrying her as a med student and perhaps that makes me just as responsible for her, I don't know. Anyway, I feel terrible. Does anyone have any advice

 

[Bobblehead]

It can be comforting at times for family to have a physician (or adequate substitute besides a nurse) at the bedside as the patient is dying. It allows you to explain the various stages of dying, the beeping of the monitors, the inevitable last few deep gasps as the brain senses the hypoxemia, assure them that the patient isn't feeling any pain, that hearing is likely the last sense to go and to assume the patient can hear the family, etc. It may be helpful if they end up foaming at the mouth to suction the secretions, provide a scopolamine patch to avoid the death rattle, etc.

From your limited information, if death was expected and imminent having the family aware of this and perhaps in the room as she is dying (if they so choose) may be helpful. Depending on the situation it may at times be helpful to have them watch the ACLS algorithm. Most families rapidly tell you to stop when they watch chest compressions (totally useless for hyperkalemia) as they come to realize this isn't what their family member would want. Sometimes it also helps allay suspicion that for whatever reason the doctors have decided to let their family member die.

You will see plenty of death in the MICU. Sometimes the best care we can provide to a patient is death with dignity and you'll need to know how to carry yourself in these situations. Residency provides little formal instruction on how to deal with the dying process, how to help families through the dying process and what you can do to ease suffering. Each dying patient can teach you a little about the process.

Depending on your institution you'll also be asking for a post-mortem and having established a relationship with the family prior to that point in time may be helpful in that.

I wouldn't worry about becoming too involved, you can show empathy and still be able to go for lunch after going through something like that in the end. It just takes practice.

 

[doraku]

The family was notified and on their way from the airport. ETA was two hours after I left...probably too late. They did not want chest compressions or defib. I guess more of a chemical code.

 

[stoic]

I am currently in the MICU and have been carrying a patient who is literally on her deathbed. Today her K+ was well above 8.0 and her EKG started going through the expected changes at about 2pm. At that point, I had finished my work but wanted to stick around to see what would happen. By 4pm, I noticed I was meticulously calibrating her EKG and watching it slowly turn into a sine wave (but not quite). I don't know if it was the sadness of literally watching someone die or the fact that I had seen a patient die in front of me but I did not want to stay. I mentioned to the resident that I had finished all my notes, offered to help him with his work (he declined), and then suggested that I leave because I was getting upset. He looked at me with surprise and said "it shouldn't be too much longer," implying I should stay and was teased by the other residents for wanting to see her EKG convert to sine then asystole (which he admitted to). So I stayed for another half hour but I couldn't stand to watch that stupid EKG as the nurse got the atropine ready and we paged through ACLS protocol. Not to mention the fact that everyone was wrapped up in their work and I was left with this half dead women to watch her demise. I finally left and got a surprised reaction from the resident along with a dismissive "okayyy". Was that bad? Should I have stayed until she coded? I feel so horrible but on the other hand I also know that I will be in that situation more times than I can count and its not pleasant. I didn't want to see everyone rush in for the code or the family start screaming in despair when they find out their loved one passed. Although I realize I should not avoid that situation, I don't understand why I should subject myself to it unnecessarily. I was carrying her as a med student and perhaps that makes me just as responsible for her, I don't know. Anyway, I feel terrible. Does anyone have any advice

hi. welcome to being a doctor.

 

[imtiaz]

it was your first time, you'll learn to get used to things like this. my first time watching a pt die and doing an autopsy was weird, but it gets easier and easier to do each time. don't beat yourself up over it.

 

[doraku]

hi. welcome to being a doctor.

2009, huh? We'll talk when you get there.

 

[stoic]

2009, huh? We'll talk when you get there.

while shadowing i've been with several patients as they die. it is a weird feeling, but i still think you should have stayed. after all, they're the ones who are dying; if it's hard for you how hard is it for them? how would you feel if someone was taking care of you (even if a med student) and left b/c they couldn't handle it?

 

[bts4202]

I am currently in the MICU and have been carrying a patient who is literally on her deathbed. Today her K+ was well above 8.0 and her EKG started going through the expected changes at about 2pm. At that point, I had finished my work but wanted to stick around to see what would happen. By 4pm, I noticed I was meticulously calibrating her EKG and watching it slowly turn into a sine wave (but not quite). I don't know if it was the sadness of literally watching someone die or the fact that I had seen a patient die in front of me but I did not want to stay. I mentioned to the resident that I had finished all my notes, offered to help him with his work (he declined), and then suggested that I leave because I was getting upset. He looked at me with surprise and said "it shouldn't be too much longer," implying I should stay and was teased by the other residents for wanting to see her EKG convert to sine then asystole (which he admitted to). So I stayed for another half hour but I couldn't stand to watch that stupid EKG as the nurse got the atropine ready and we paged through ACLS protocol. Not to mention the fact that everyone was wrapped up in their work and I was left with this half dead women to watch her demise. I finally left and got a surprised reaction from the resident along with a dismissive "okayyy". Was that bad? Should I have stayed until she coded? I feel so horrible but on the other hand I also know that I will be in that situation more times than I can count and its not pleasant. I didn't want to see everyone rush in for the code or the family start screaming in despair when they find out their loved one passed. Although I realize I should not avoid that situation, I don't understand why I should subject myself to it unnecessarily. I was carrying her as a med student and perhaps that makes me just as responsible for her, I don't know. Anyway, I feel terrible. Does anyone have any advice

You need to stay in the room or at least be nearby and when the pt does actually arrest, you need to be there. You also need to be there to pronounce the pt when that time comes. There is no way to actually gain experience with your patients dying unless you are actually there for their death. All you have done is delayed the time when you must have your first experience. It is better to do it now when you are a med student and can cry and be upset and your superiors will be more understanding.

I have a friend who was told by an attending to just go sit in the room with a dying pt cause it was good experience. Even though the med student had never seen the pt or had anything to do with the care of the pt. Personally, I think that is a terrible idea. However, in this case, this pt had been under your care... it then becomes partly your responsibility to help the patient pass in a dignified and compassionate way... regardless of your fear.... and the emotions and experience it gives you is highly valuable IMHO.

 

[sacrament]

Seperate from the whole "dying patient" issue, leaving the hospital when your resident explicitly says you should stay is like commiting grade suicide. I don't even so much as glance toward the elevators without a go-ahead, I can't imagine just up-and-leavin'.

 

[doraku]

its one of my fourth year electives. and the resident was an intern. my gut feeling still tells me I shouldn't have chickened out but i doubt it will have any bearing on anything. worst case scenario, the intern thinks i'm a wuss/slacker and tells the attending but even then all the attending can think is that i'm avoiding the death scenario. can you blame me? i'm not really worried about grades at this point, i'm just trying to figure out where my place is in this situation.

 

[stoic]

its one of my fourth year electives. and the resident was an intern. my gut feeling still tells me I shouldn't have chickened out but i doubt it will have any bearing on anything. worst case scenario, the intern thinks i'm a wuss/slacker and tells the attending but even then all the attending can think is that i'm avoiding the death scenario. can you blame me? i'm not really worried about grades at this point, i'm just trying to figure out where my place is in this situation.

just out of curiosity, how are you gonna deal with it next year when you're the intern who's taking care of the patient while they die?

 

[electra]

I think instead of beating yourself up over it, learn what you can and move on. This is a very difficult situation; it keeps people out of the medical field and out of certain specialties where they don't (really, personally) have to deal with patient death.

Should you have stayed? Probably. But sometimes you are not emotionally equipped to stay and participate in the end. If that was how you felt, then forgive yourself and move on. You are right in saying that you will have many more experiences like this in your career.

2009, try to wait until it's you in the position to comment.

And other like me, who are finishing 4th year and going into internship, try and remember what it was like the first time one of YOUR patients died. And make sure that your students understand what is going on and why it is important to see and go through the experience.

 

[tupac_don]

I am currently in the MICU and have been carrying a patient who is literally on her deathbed. Today her K+ was well above 8.0 and her EKG started going through the expected changes at about 2pm. At that point, I had finished my work but wanted to stick around to see what would happen. By 4pm, I noticed I was meticulously calibrating her EKG and watching it slowly turn into a sine wave (but not quite). I don't know if it was the sadness of literally watching someone die or the fact that I had seen a patient die in front of me but I did not want to stay. I mentioned to the resident that I had finished all my notes, offered to help him with his work (he declined), and then suggested that I leave because I was getting upset. He looked at me with surprise and said "it shouldn't be too much longer," implying I should stay and was teased by the other residents for wanting to see her EKG convert to sine then asystole (which he admitted to). So I stayed for another half hour but I couldn't stand to watch that stupid EKG as the nurse got the atropine ready and we paged through ACLS protocol. Not to mention the fact that everyone was wrapped up in their work and I was left with this half dead women to watch her demise. I finally left and got a surprised reaction from the resident along with a dismissive "okayyy". Was that bad? Should I have stayed until she coded? I feel so horrible but on the other hand I also know that I will be in that situation more times than I can count and its not pleasant. I didn't want to see everyone rush in for the code or the family start screaming in despair when they find out their loved one passed. Although I realize I should not avoid that situation, I don't understand why I should subject myself to it unnecessarily. I was carrying her as a med student and perhaps that makes me just as responsible for her, I don't know. Anyway, I feel terrible. Does anyone have any advice

You should have stayed for sure. On one hand it is a little morbid, sure. But bottom line you need to grow a thick skin and you need to be able to see what's going on during a code. When I went to codes I was very excited to watch. It is part of a learning expereince. Your resident is probably very enthusiastic about medicine, and saw this as lack of enthusiasm on your part. For sure you should have stayed. If you find a person dying in front of your eyes then you shouldn't be in medicine. I mean that is your job, to save people. Unfortunately you cannot save everyone and you will have to deal with death. You just gotta do it without affecting you emotionally. Gotta distance yourself. Can be hard for some people sure, but at the same time you wanna be a doctor. You must get over it.

 

[macman]

I think the situation really highlights the transition from student to intern. I know what the orig. poster is talking about-as students we tend to focus on "what am I getting out of this" and as an intern its "this is my patient"--it sounds like a good learning experience-as much as you want to leave-stay when its your patient-leave when its someone elses (unless you are covering)

my 2 cents

 

[Harrie]

You should have stayed because it was YOUR patient. You need to start taking ownership of your patients, especially if you're a fourth year.

 

[doc05]

death is no fun. it's best to find a specialty with minimal exposure to dying patients...and a smart choice of specialty will make you a happier, more easygoing person.

 

[phoenixsupra]

I can't believe no one has said this. Stay and console the family if there is really nothing else you could do. As a med student sometimes that's the most useful thing you can do. Face it no one else has the time. And it means a whole lot to people. If you're confused in a situation like that ask yourself "what would I do if I wasn't a medical student". Just help them in whatever way you can. Sometimes I think we have our common sense "educated" out of us.

Or you could watch how your resident handles the situation. Well, ok, badly etc What would you do different. That way when you're in their situation it wont be square one. Freaking out is no big deal. But next time affect the situation for the better...somehow.

 

[fourthyearmed]

I'm just curious what field you're going into. If you're going into medicine you probably should have stayed just to learn how to handle the situation. On the other hand, if you're headed to Path or Derm it probably doesn't matter.

 

[hotlikebutter]

maybe death was the best thing for the patient, didnt you want the patient to pass on? was there already a lot of suffering already taking place?sometimes doctors can do too much, and sometimes they just need to let it go. this is all easier said than done. yes you IMO you should have stayed, but you are student, learn from this. no use in dwelling on it now. also, my mentor who has been a doctor for decades says you will never get over people dying, you just think about it differently and move on because you owe it to your other patients and to yourself.

 

[Leforte]

The only question I would have is why were they watching the patients K+ and EKG changes and getting ready for a code? If the patient is not DNR and wants all efforts, shouldn't they be aggressively treating the hyperkalemia instead of reviewing ACLS protocols and getting atropine ready for when asystole ensues?

 

[roja]

2009, huh? We'll talk when you get there.

hi. welcome to being a doctor.


now, having that out of the way, you should learn from this and move on. Yes, you probably should have stayed. Watching someone die is not easy, but being an MD isn't about being easy. And the really good MD's go the extra step and participate in the things that are difficult. You should have stayed, if for no other reason, when the family comes in, you can talk to them about what happend and let them know that someone was there.


Regarding the patient, there is no chemical resuscitation. either you will go through ACLS or not.

If the patient was not DNR, then the K should have been dealt with. If the patient was DNR, then attempts to make the patient comfortable, etc should have been made. Your itnern should have been there as well.

dont' beat yourself up. and its okay to be upset. I have gotten tearful with patients families before. They appreciate that you are human.

 

[Gene Queen]

I agree with the above post. What good is atropine, etc, going to do? Or does the family want to be there when she dies?

 

[Apollyon]

Death is a natural part of life, but, even in the face of that, many people (if not virtually everyone in the world) are not there at the moment of death (even when they call the code - the first time - in the hospital, most people that come are coming from somewhere else, after the patient has passed). Experiencing the death of a patient is a rarefied incident. It is not wrong to be emotional, as long as you keep your head - that is the difference between professional (doctor) and the lay public. I would not go so far as to call it a "rite of passage" (there are many fine doctors that have never run a code, or been there when their patient expired), but, given the opportunity, it is something that can provoke reflection on feelings that may be unexplored, and, in my opinion, can only help your professional development.

 

[goooooober]

Here is my take. She was your patient and you should have stayed with her to the very end, PERIOD. Nobody wants a physician that is going to abandon them at the end. In fact, you should have held the patient's hand and waited. Don't take your personal opinions, sensitivities, phobias, ideas, problems and whatever else to work. Just take care of your patients until they have either recovered or have passed on.

 

[phoenixsupra]

Don't take your personal opinions, sensitivities, phobias, ideas, problems and whatever else to work. Just take care of your patients until they have either recovered or have passed on.

goober, how can someone not take a phobia to work?? It's not like it's some sort of bolt on accessary. Most people with phobias can't just turn it off with a switch. As for sensitivity - please DO bring that to work. It's necessary. For the most part what you say isn't untrue. But it's all easier said than done. Might be more useful if you try telling her HOW to do these things you mention. 😉

 

[scootad.]

your going into psych right?

 

[phoenixsupra]

your going into psych right?

Ha ha. You talkin to me?? 😀 No, I'm going into surgery. Really, this is sort of a common sense issue. Even surgeons have been known to posess that faculty. 😉

 

[macman]

Here is my take. She was your patient and you should have stayed with her to the very end, PERIOD. Nobody wants a physician that is going to abandon them at the end. In fact, you should have held the patient's hand and waited. Don't take your personal opinions, sensitivities, phobias, ideas, problems and whatever else to work. Just take care of your patients until they have either recovered or have passed on.

Thats a little harsh-it may be valid-but we are all learning and its a process-judge not lest you be.....

 

[starayamoskva]

I am currently in the MICU and have been carrying a patient who is literally on her deathbed. Today her K+ was well above 8.0 and her EKG started going through the expected changes at about 2pm. At that point, I had finished my work but wanted to stick around to see what would happen. By 4pm, I noticed I was meticulously calibrating her EKG and watching it slowly turn into a sine wave (but not quite). I don't know if it was the sadness of literally watching someone die or the fact that I had seen a patient die in front of me but I did not want to stay. I mentioned to the resident that I had finished all my notes, offered to help him with his work (he declined), and then suggested that I leave because I was getting upset. He looked at me with surprise and said "it shouldn't be too much longer," implying I should stay and was teased by the other residents for wanting to see her EKG convert to sine then asystole (which he admitted to). So I stayed for another half hour but I couldn't stand to watch that stupid EKG as the nurse got the atropine ready and we paged through ACLS protocol. Not to mention the fact that everyone was wrapped up in their work and I was left with this half dead women to watch her demise. I finally left and got a surprised reaction from the resident along with a dismissive "okayyy". Was that bad? Should I have stayed until she coded? I feel so horrible but on the other hand I also know that I will be in that situation more times than I can count and its not pleasant. I didn't want to see everyone rush in for the code or the family start screaming in despair when they find out their loved one passed. Although I realize I should not avoid that situation, I don't understand why I should subject myself to it unnecessarily. I was carrying her as a med student and perhaps that makes me just as responsible for her, I don't know. Anyway, I feel terrible. Does anyone have any advice

Why didn't someone talk to the family about making her a DNR, D/C the heart monitor and transfer her out to a regular room so that her family could be with her?

She was your patient, you should have stayed.

 

[goooooober]

goober, how can someone not take a phobia to work?? It's not like it's some sort of bolt on accessary. Most people with phobias can't just turn it off with a switch. As for sensitivity - please DO bring that to work. It's necessary. For the most part what you say isn't untrue. But it's all easier said than done. Might be more useful if you try telling her HOW to do these things you mention. 😉

Let me clarify for the slow one. when i said sensitivity i did not mean empathy and sympathy. I meant overreacting. I did not mean phobia in the literal sense, but rather figurative. As far as how to do it, here is a clue, stay in the room with your patient (just to clarify for phoenixsupra, you can sit on a chair or stand).

Macman, I don't think telling someone that they should have stayed in the room is harsh. Does that mean that I am perfect and that I wouldn't make that mistake? Absolutely not. But, being physicians, we have to try to always follow certain moral/ethical standards. I was just presenting my belief of what the moral/ethical thing to do is in his situation.

 

[phoenixsupra]

Let me clarify for the slow one. when i said sensitivity i did not mean empathy and sympathy. I meant overreacting. I did not mean phobia in the literal sense, but rather figurative. As far as how to do it, here is a clue, stay in the room with your patient (just to clarify for phoenixsupra, you can sit on a chair or stand).

goober, I hope for your sake you don't go around talking to people like that in person. You come off as stuffy and obnoxious. I don't know if that is your intent or just a style you have been unfortunate enough to end up with. It's something you could change. Think about it. Fortunately at this stage most of us know that that kind of snot-nosed drivel is a front for poor self esteem. In any case your writing is not clear. It needs some work. What is a phobia "in the figurative sense" anyway. You're talking garbage now. Say what you mean in the first place. And here's a hint. Read back through it and see if it's something you'd like to have someone say to you. 😉

Macman, I don't think telling someone that they should have stayed in the room is harsh. Does that mean that I am perfect and that I wouldn't make that mistake? Absolutely not. But, being physicians, we have to try to always follow certain moral/ethical standards. I was just presenting my belief of what the moral/ethical thing to do is in his situation.

Macman is talking about your TONE. It is harsh. Soften it a bit or people will think you are a jerk. I don't know if that is the case, but it is how you're coming off so give it a little thought. There's nothing either moral or ethical about being an emotional idiot. Good luck. 🙂

 

[scootad.]

heh yer so not a surgeon 😉

 

[phoenixsupra]

heh yer so not a surgeon 😉

Yeah, I don't fit the stereotype. I take that as a compliment. 🙂 Most surgeons I know don't fit it either. I had fun chating with you on that other thread last night BTW. You're so not a radiologist 😉

 

[Mossjoh]

I was going to say...umm, why don't we treat the hyperkalemia? Calcium gluconate, dextrose/insulin, kayexalate anyone?

Why was this patient not treated? DNR does not mean don't do anything. DNR should mean DNAR....its about once they are in asystole or clinically dead..not treating them while they are alive!